ISSUE BRIEF No. 4383 | APRIL 14, 2015 Global Experience Shows that Physician-Assisted Suicide Threatens the Weak and Marginalized Ryan T. Anderson, PhD llowing physician-assisted suicide (PAS) would The Task Force members unanimously conclud- Abe a grave mistake for four reasons, as explained ed that legalizing assisted suicide and euthanasia in a Heritage Foundation Backgrounder, “Always would pose profound risks to many patients.… Care, Never Kill.”1 First, it would endanger the weak and vulnerable. Second, it would corrupt the prac- tice of medicine and the doctor–patient relationship. …The practices will pose the greatest risks to Third, it would compromise the family and intergen- those who are poor, elderly, members of a minori- erational commitments. And fourth, it would betray ty group, or without access to good medical care.… human dignity and equality before the law. Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence. …The clinical safeguards that have been proposed This Issue Brief focuses on how PAS threatens to prevent abuse and errors would not be realized the weak and marginalized. It explores who is most in many cases.2 likely to be coaxed into PAS and how PAS has led to voluntary—and even involuntary—euthanasia in The people most likely to be assisted by a physi- Europe. This lethal logic has even been extended to cian in their suicide are suffering not simply from children and the non-terminally ill disabled. terminal illness, but also from depression, men- tal illness, loneliness, and despair. “Researchers Physician-Assisted Suicide Threatens the have found hopelessness, which is strongly cor- Weak and Marginalized related with depression, to be the factor that most Physician-assisted suicide will most threaten significantly predicts the wish for death,” write the weak and marginalized because of the cultural Dr. Herbert Hendin and Dr. Kathleen Foley. As Dr. pressures and economic incentives that will drive Hendin reports: it. The New York State Task Force on Life and the Law, established by Governor Mario Cuomo (D), Mental illness raises the suicide risk even more explained in its report: than physical illness. Nearly 95 percent of those who kill themselves have been shown to have a diagnosable psychiatric illness in the months This paper, in its entirety, can be found at preceding suicide. The majority suffer from http://report.heritage.org/ib4383 depression that can be treated. This is particu- The Heritage Foundation 214 Massachusetts Avenue, NE larly true of those over fifty, who are more prone Washington, DC 20002 than younger victims to take their lives dur- (202) 546-4400 | heritage.org ing the type of acute depressive episode that Nothing written here is to be construed as necessarily reflecting the views 3 of The Heritage Foundation or as an attempt to aid or hinder the passage responds most effectively to treatment. of any bill before Congress. ISSUE BRIEF | NO. 4383 APRIL 14, 2015 From their decades of professional medical The World’s Experience with practice, Drs. Hendin and Foley report that when Physician-Assisted Suicide Laws patients who ask for a physician’s assistance in sui- Confirms the Lethal Logic cide “are treated by a physician who can hear their While many assisted-suicide laws attempt to desperation, understand the ambivalence that most limit PAS eligibility to the terminally ill, and while feel about their request, treat their depression, and many laws attempt to provide protections ensuring relieve their suffering, their wish to die usually autonomous consent, the experience of countries disappears.”4 They conclude: “Patients requesting with PAS and euthanasia suggests that safeguards suicide need psychiatric evaluation to determine fail to ensure effective control. whether they are seriously depressed, mentally In 1989, while teaching law and medical ethics at incompetent, or for whatever reason do not meet the the University of Cambridge, Professor John Keown criteria for assisted suicide.”5 began to investigate PAS and euthanasia in the Neth- Yet only five of the 178 Oregon patients who died erlands. He found that key Dutch guidelines, such as under the Oregon assisted-suicide laws in 2013 and requiring an explicit request from the patient, have 2014 were referred for any psychiatric or psychologi- long been widely violated with virtual impunity.8 He cal evaluation. Remarkably, patients were referred pointed out that the first of several official surveys for psychiatric evaluation in less than 5.5 percent of conducted by the Dutch found that in 1990 “the total the 859 cases of assisted suicide reported in Oregon number of life-shortening acts and omissions where since its law went into effect in 1997.6 “This consti- the doctor’s primary intention…was to kill, and which tutes medical negligence,” writes Dr. Aaron Kheri- are therefore indubitably euthanasiast, is 10,558.”9 aty. Dr. Kheriaty concludes, “To abandon suicidal Shockingly, the majority of these cases were non- individuals in the midst of a crisis—under the guise voluntary. Oxford legal scholar John Finnis, com- of respecting their autonomy—is socially irresponsi- menting on the Dutch data, remarks: “[W]ell over ble: It undermines sound medical ethics and erodes half…were without any explicit request. In the Unit- social solidarity.”7 ed States that would be over 235,000 unrequested medically accelerated deaths per annum.”10 In 2013, 1.7 percent (1,807 patients) of all deaths in Belgium were due to euthanasia and physician-assisted 1. See Ryan T. Anderson, “Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality,” Heritage Foundation Backgrounder 3004, March 24, 2015, http://www.heritage.org/ research/reports/2015/03/always-care-never-kill-how-physician-assisted-suicide-endangers-the-weak-corrupts-medicine-compromises- the-family-and-violates-human-dignity-and-equality. 2. New York Department of Health, Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context, May 1994, https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/preface.htm (accessed April 13, 2015). 3. Herbert Hendin, Seduced by Death: Doctors, Patients, and Assisted Suicide (New York: W.W. Norton, 1998), pp. 34–35. 4. Herbert Hendin and Kathleen Foley, “Physician-Assisted Suicide in Oregon: A Medical Perspective,” Michigan Law Review, Vol. 106, No. 8 (June 2008), pp. 1625–1626. 5. Ibid., p. 1622. 6. Oregon Public Health Division, “Oregon’s Death with Dignity Act—2014,” http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf (accessed April 13, 2015). 7. Aaron Kheriaty, “Apostolate of Death,” First Things, April 2015, p. 19. 8. See John Keown, “Euthanasia in the Netherlands: Sliding down the Slippery Slope?” Notre Dame Journal of Law, Ethics & Public Policy, Vol. 9, No. 2 (1995), http://scholarship.law.nd.edu/cgi/viewcontent.cgi?article=1427&context=ndjlepp (accessed April 13, 2015). 9. Ibid., p. 423 (emphasis in original). 10. John Finnis, The Collected Essays of John Finnis, Vol. 3, Human Rights and Common Good (Oxford: Oxford University Press, 2011), p. 255. 2 ISSUE BRIEF | NO. 4383 APRIL 14, 2015 suicide.11 A 2010 study discovered that 66 of 208 iden- incapable of asking for it?… The logical “slippery tified deaths in Belgium were administered without slope” argument is unanswerable.16 an explicit patient request.12 Keown confirms that “theundisputed empiri- Dr. Ezekiel Emanuel, writing in the Atlantic cal evidence from the Netherlands and Belgium Monthly, affirms that this is the lesson to take from shows widespread breach of the safeguards, not the Netherlands and that proposed American PAS least the sizeable incidence of non-voluntary eutha- laws cannot avoid the same outcome: nasia and of non-reporting.”13 In October of 2013, three judges of the High Court of Ireland voiced the The Netherlands studies fail to demonstrate that same concern: “[T]he incidence of legally assisted permitting physician-assisted suicide and eutha- death without explicit request in the Netherlands, nasia will not lead to the nonvoluntary euthana- Belgium and Switzerland is strikingly high.”14 And sia of children, the demented, the mentally ill, the numbers of those assisted in committed suicide the old, and others. Indeed, the persistence of keep growing.15 abuse and the violation of safeguards, despite Part of the reason for these troubling statistics publicity and condemnation, suggest that the is that any purported legal safeguards can be and feared consequences of legalization are exactly its have been abused, and over time the logic of a “right inherent consequences.17 to die” is extended to ever-wider groups of patients, including the incompetent. Keown describes the logic of PAS as based on judging some lives as The Lethal Logic Extends unworthy of life: to Children and Disabled In 1996, two doctors prosecuted in the Nether- Once a doctor is prepared to make such a judg- lands for the nonvoluntary euthanasia of disabled ment in the case of [a] patient capable of request- infants were acquitted when they argued medical ing death, the judgment can, logically, equally be necessity.18 The Dutch courts simply followed the made in the case of a patient incapable of request- inexorable logic that drives the case for PAS and vol- ing death.… If a doctor thinks death would ben- untary euthanasia to a new extent. If necessity justi- efit the patient, why should the doctor deny the fies ending the life of a suffering patient who requests patient that benefit merely because the patient is it, it equally justifies ending the life of a suffering 11. Government of Belgium, Commission Fédérale de Contrôle, Et D’évaluation de L’euthanasie, 2014, p. 7, http://www.health.belgium.be/filestore/19097638/Rapport_Euthanasie12-13_FR.pdf (accessed April 13, 2015).